Vaccine-Preventable Disease Control in the Western Pacific Region

Vaccine-Preventable Disease Control in the Western Pacific Region

Mark Jacobs Director, Communicable Diseases

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OutlineOutline

Regional goals Disease-specific updates

– Hepatitis B– Measles– Polio– Rubella– Tetanus

Remaining challenges

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Regional goals related to specific vaccine-preventable diseases

Regional goals related to specific vaccine-preventable diseases

Hepatitis B: Reduce chronic infection rate among 5-year-olds to less than 1%

Japanese encephalitis: To accelerate control Measles: To achieve and sustain measles elimination Polio: Sustain regional polio-free status until global

certification; eliminate vaccine-derived poliovirus risk Rubella: Eliminate rubella and prevent congenital rubella

syndrome Tetanus: By 2015 to achieve maternal and neonatal

tetanus (MNT) elimination

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Hepatitis B goalHepatitis B goal

64th WHO WPRO Regional Committee Meeting, October 2013

Resolution WPR/RC64.R5:

The Western Pacific Region should aim to reduce HBsAg seroprevalence to less than 1% in 5-year-old children by 2017;

– Ensure at least 95% coverage of the eligible population at the national level of the hepatitis B vaccination regimen (including the birth dose), and at least 85% coverage in all districts

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Hepatitis B birth dose coverage improvement strategies

Hepatitis B birth dose coverage improvement strategies

Increase health facility deliveries

Increase hepatitis B education during ANC

Increase links with communities and outreach vaccination

Use hepatitis B outside the cold chain where needed (with guidelines and NRA approval)

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Hepatitis B vaccination coverage,Western Pacific Region, 1990-2014Hepatitis B vaccination coverage,Western Pacific Region, 1990-2014

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Vaccination

Coverage

(

%)

HepB3 Coverage HepB Birth Dose Coverage

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Status of verification towards reaching the <1% prevalence goal, WPR, 2015

Status of verification towards reaching the <1% prevalence goal, WPR, 2015

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Impact of hepatitis B vaccination and birth dose

Impact of hepatitis B vaccination and birth dose

>7 million deaths estimated to have been prevented by hepatitis B vaccination in the Western Pacific Region in the past 25 years

548 094 deaths prevented by hepatitis B vaccination among children born in 2014

Regional hepatitis B prevalence now estimated to be 0.96% among children in 2012 birth cohort (those who will be 5 years old in 2017)

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Key challenges for hepatitis BKey challenges for hepatitis B

Birth dose vaccination coverage is still low in several countries (Lao PDR, Papua New Guinea, the Philippines, Solomon Islands, Viet Nam)

Recent hepatitis B related AEFIs led to increased vaccination hesitancy in some countries

Even with high coverage, substantial numbers of new infections (50 000) are occurring among new birth cohorts in China

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Goal of measles eliminationGoal of measles elimination

In 2005, WPRO Regional Committee resolved to achieve measles elimination by 2012

In 2012, WPRO Regional Committee reaffirmed its commitment to eliminate measles as quickly as possible

The World Health Assembly endorsement of the Global Vaccine Action Plan includes goals that:

– By 2015, four of six WHO regions achieve measles elimination– By 2020, five of six WHO regions achieve measles elimination

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Key facts on measles eliminationKey facts on measles elimination

Measles is one of the leading causes of death among young children even though a safe and cost-effective vaccine is available

In 2013, there were 145 700 measles deaths globally – about 400 deaths every day or 16 deaths every hour

Measles vaccination resulted in a 75% drop in measles deaths between 2000 and 2013 worldwide

In 2013, about 84% of the world's children received one dose of measles vaccine by their first birthday through routine health services – up from 73% in 2000

During 2000-2013, measles vaccination prevented an estimated 15.6 million deaths making measles vaccine one of the best buys in public health

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Key strategies for measles eliminationKey strategies for measles elimination

Achieve and maintain high (>95%) coverage with two doses of measles containing vaccine

Monitor disease using effective case based surveillance

Develop and maintain outbreak preparedness

Communicate and engage the community to create demand for vaccination

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Reported Measles Incidence Rate*,Jul 2014 to Jun 2015

Reported Measles Incidence Rate*,Jul 2014 to Jun 2015

*Rate per 1'000'000 population

Data source: surveillance DEF fileData in HQ as of 10 August 2015

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. ©WHO 2015. All rights reserved.

<1 (73 countries or 38%)≥1 - <5 (36 countries or 19%)

≥5 - <10 (18 countries or 9%)

≥10 - <50 (30 countries or 15%)

≥50 (20 countries or 10%)No data reported to WHO HQ

(17 countries or 9%)

Not applicable

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Reported confirmed measles cases by month of onset, Jan 2010-Jun 2015, Western Pacific Region Reported confirmed measles cases by month of

onset, Jan 2010-Jun 2015, Western Pacific Region

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Categories Countries, Areas,Epidemiological Blocks

1 Verified as having achieved elimination

Australia, Brunei Darussalam, Cambodia, Japan, Macao (China), Mongolia, Republic of Korea (n=7)

2<36 months since achieving interruption of endemic measles transmission

New Zealand (n=1)

3 May be ready for verification but additional information needed

Hong Kong SAR (China), Singapore (n=2)

4 Periods with low/no documented transmission followed by outbreaks

Lao People’s Democratic Republic, Pacific islands (n=2)

5 Ongoing measles virus transmission China, Malaysia, Papua New Guinea, the Philippines, Viet Nam (n=5)

Summary of Progress Towards Measles Elimination, as assessed by the Regional Verification Commission, March 2015

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Key challenges in measles elimination

Measles virus is one of the most (or perhaps the most) infectious of all viruses

Very high (>95%) population immunity required

Complacency or vaccine hesitancy because measles is considered a “benign childhood illness” rather than recognized as the fifth leading cause of death among children under 5 years of age

Immunity gaps among very young children (eg too young to be vaccinated) and adult populations that missed vaccination and not previously infected

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1954: Jonas Salk develops a killed polio virus.

1961: Albert Sabin develops an oral polio vaccine.

1988 World Health Assembly resolved to eradicate polio by 2000

Goal of polio eradicationGoal of polio eradication

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Progress on polio eradicationProgress on polio eradication

1988: 125 countries; 350,000 cases per year

2015: 2 countries with reported cases; 36 cases year to date

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Poliovirus types– Type 1: Ongoing transmission– Type 2: Last reported from India in 1999 – Type 3: Last reported from Nigeria in 2012

Regional certification of polio-free status– 1994: Region of the Americas – 2000: Western Pacific Region– 2002: European Region– 2014: South East Asia Region– 2014: Last wild poliovirus case reported from African Region

Progress on polio eradicationProgress on polio eradication

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Key strategies for polio eradicationKey strategies for polio eradication

Poliovirus detection and interruption: Maintaining sensitive surveillance systems worldwide

Strengthening immunization systems and withdrawal of OPV: Introduce at least one dose of IPVand switch from tOPV to bOPV

Containment and certification: Contain polioviruses and potentially infected waste to prevent accidental reintroduction

Legacy planning: Turn over polio programme assets for use in other disease control programmes

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IPV introduction in the Western PacificIPV introduction in the Western Pacific

OPV country/area eligible for GAVI support for IPV

OPV country/area  not GAVI eligible

IPV using country/area

Country/area with sequential (IPV/OPV) schedule

Approximate number of live births 2012 (JRF)

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Key challenges for polio eradication

Reaching children in insecure border area of Afghanistan and Pakistan where polio workers have been killed

Polio eradication is not just the job of polio-infected countries; all countries should

– Maintain high population immunity– Maintain sensitive surveillance for acute flaccid paralysis

Very rapid timelines for IPV introduction

Identification and containment of all polioviruses and potentially infectious material in all laboratories (private and public) world wide

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Goal of rubella eliminationGoal of rubella elimination

In 2012, World Health Assembly endorsed the Global Vaccine Action Plan goals that:

– By 2015, two of six WHO regions achieve rubella elimination– By 2020, five of six WHO regions achieve rubella elimination

In 2013, the Regional Committee for the Western Pacific resolved to eliminate rubella and prevent congenital rubella syndrome (CRS)

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0 2,100 4,2001,050 Kilometers

Rubella incidence per million, 2014Rubella incidence per million, 2014

Source: Joint Reporting Form as at 15 May 2015.194 WHO Member States. Map production: Immunization Vaccines and Biologicals, (IVB). World Health OrganizationDate of slide: 15 May 2015

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2015. All rights reserved

<1 case per million (82 countries or 42%)

Not applicable

>1--<5 (21 countries or 11%)

>5--<10 (12 countries or 6%)>10--<50 (12 countries or 6%)

>= 50 (7 countries or 4%)

Not available / No data reported to WHO HQ (60 countries or 31%)

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Vaccination for rubella in the Western Pacific Region

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Australia, New Zealand, the Republic of Korea and Singapore have been approaching rubella elimination

Japan developed and officially issued a national plan and strategy for rubella elimination in 2014 and determined 2020 as target year

Mongolia aims to eliminate rubella by 2020 and has started development of a National Strategy for Measles and Rubella Elimination 2016-2020

Cambodia will start development of a national plan and strategy for rubella elimination

Regional progress toward rubella eliminationRegional progress toward rubella elimination

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Key strategies for rubella eliminationKey strategies for rubella elimination

Use only combination measles-rubella vaccines for all routine and supplementary doses

Monitor rubella disease and occurrence of CRS using sensitive case based surveillance

Communicate with and engage community to create demand for vaccination

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Key challenges for rubella elimination

Disease control programme is not as well established as measles; many countries do not include rubella as reportable disease

Three countries in region have not yet introduced rubella vaccine into routine programme, but are expected to do so by 2016 (Papua New Guinea, Vanuatu, and Viet Nam)

In the past, many countries vaccinated only girls, which leaves a large susceptible pool for disease transmission among adult men

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Maternal and Neonatal Tetanus EliminationMaternal and Neonatal Tetanus Elimination

The World Health Assembly first called for elimination of neonatal tetanus in 1989

In 1999, goal was expanded to include elimination of the maternal tetanus

– Neonatal tetanus (NT)— occurring ≤28 days of life– Maternal tetanus — occurring during or ≤6 weeks following delivery

At that time, 57 countries had not eliminated MNT

In October 2014, WHO Regional Committee for the Western Pacific endorsed goal of MNT elimination in all countries by 2015

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Key strategies for MNT EliminationKey strategies for MNT Elimination

Tetanus toxoid containing vaccine supplementary immunization campaigns for all women of reproductive age in high risk districts

Tetanus toxoid containing vaccination of pregnant women

Clean delivery and clean umbilical cord care (ideally through skilled birth attendants in health care facility setting)

Neonatal tetanus surveillance

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0 1,500 3,000 4,500 6,000750Kilometers

From 2000 to April 2015, 37 countries eliminated MNT*(Plus Ethiopia except Somali Region; 30 of 34 provinces in Indonesia; and 16 of 17 regions in Philippines)

From 2000 to April 2015, 37 countries eliminated MNT*(Plus Ethiopia except Somali Region; 30 of 34 provinces in Indonesia; and 16 of 17 regions in Philippines)

Source: WHO/UNICEF DatabaseDate of slide : 26 May 2015Map production: Immunization Vaccines and Biologicals, (IVB), World Health Organization

MNT eliminated from 2000- April 2015 (N=37)

MNT not eliminated (N=22)

MNT eliminated before 2000

Not Applicable

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Not yet validated (Papua New Guinea)

LEGEND:

Validated

16 of 17 regions validated (Philippines)

MNT elimination in the Western Pacific:Only 6 countries included in list of 59 high risk countries

Viet Nam: Validated in 2005China: Validated in 2012Lao PDR: Validated in 2013Philippines: 16/17 regions validated in Feb 2015Cambodia: Validated in June 2015Papua New Guinea: Pending

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Key challenges for MNT elimination

Philippines: Insecurity in the Autonomous Region of Muslim Mindanao

Papua New Guinea: Competing priorities for scarce resources in a setting of developing health care delivery system

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In conclusion Enormous strides made by countries of WPR in tackling VPD

Elimination of measles and rubella, and eradication of polio, is within our grasp

Some key challenges remain-– Expanding coverage in hard to reach groups– Maintaining national focus as case numbers drop– Retaining community support– Balancing opportunities re new vaccines with achieving and sustaining necessary

coverage with existing vaccines– Reduced donor support for immunisation in some countries, adding to difficulty of

maintaining national focus and building on past success